PROVIDER MANUAL COMMERCIAL PLANS - PRV1_0719_V2 - PACIFICSOURCE
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Provider Manual
Commercial Plans
PRV1_0719_v2
Covered Expenses, General Exclusions, and Limitations For reference, sample plan policies and handbooks are available online on PacificSource.com. These outline coverage, as well as exclusions and limitations. Find plan summary pages at Pacificsource.com/plan-summaries and sample plan policies and handbooks for each state and type of plan as follows: Idaho 2018 Small group plans: https://pacificsource.com/idaho/small-2018/ Large group plans: https://pacificsource.com/idaho/large-2018/ 2019 Individual plans: https://pacificsource.com/idaho/individual-2019/ Small group plans: https://pacificsource.com/idaho/small-2019/ Large group plans: https://pacificsource.com/idaho/large-2019/ Montana 2018 Small group plans: https://pacificsource.com/montana/small-2018/ Large group plans: https://pacificsource.com/montana/large-2018/ 2019 Individual plans: https://pacificsource.com/montana/individual-2019/ Small group plans: https://pacificsource.com/montana/small-2019/ Large group plans: https://pacificsource.com/montana/large-2019/ Oregon 2018 Small group plans: https://pacificsource.com/oregon/small-2018/ Large group plans: https://pacificsource.com/oregon/large-2018/ 2019 Individual plans: https://pacificsource.com/oregon/individual-2019/ Small group plans: https://pacificsource.com/oregon/small-2019/ Large group plans: https://pacificsource.com/oregon/large-2019/ Note these are sample documents, and a patient’s actual coverage may vary. Please be sure to contact us as you normally would to verify benefits or obtain preapproval.
Contents
Section 1: Introduction�����������������������������������������������������1 6.4 Utilization Management........................................33
1.1 About This Manual..................................................1 6.4.1 Nonreimbursed Nursing Level Charges
1.2 PacificSource Mission Statement .........................1 During an Acute Care Hospital Stay..........33
1.3 PacificSource History..............................................2 6.4.2 Concurrent Review....................................34
6.4.3 Retrospective Utilization............................35
Section 2: Who to Contact����������������������������������������������3 6.5 Quality Utilization Program...................................35
2.1 Provider Network Management.............................5 6.6 Clinical Practice Guidelines...................................35
Section 3: Glossary of Terms�������������������������������������������6 Section 7: Pharmacy�������������������������������������������������������36
Section 4: Physicians and Providers������������������������������13 7.1 Drug Lists...............................................................36
4.1 Eligible Providers...................................................13 7.2 Drug Preauthorization and Step Therapy
4.1.1 Eligible Mental Health and Substance Protocols................................................................36
Abuse Professional Providers....................13 7.3 Drug Limitations....................................................37
4.2 Credentialing.........................................................13 7.4 Specialty Drugs.....................................................37
4.2.1 Initial Credentialing Process.......................14 7.5 Nonformulary Requests........................................37
4.2.2 Recredentialing Process............................15 Section 8: Products���������������������������������������������������������38
4.2.3 Adequate Professional Liability 8.1 Product Descriptions.............................................38
Coverage.....................................................16 8.1.1 Products Offered in Oregon.......................38
4.2.4 Providers Not Credentialed.......................16 8.1.2 Oregon Provider Network Descriptions/
4.3 Taxpayer Identification Numbers..........................16 Product Associations..................................38
4.4 Physician and Provider Contract Provisions.........17 8.1.3 Products Offered in Idaho..........................39
4.4.1 Medical Records and Chart 8.1.4 Idaho Provider Network Descriptions/
Notes Requirements..................................18 Product Associations..................................39
4.5 Call Share Policy....................................................20 8.1.5 Products Offered in Montana....................39
4.6 Accessibility...........................................................20 8.1.6 Montana Provider Network Descriptions/
4.6.1 Behavioral Health Services........................20 Product Associations..................................39
4.6.2 Primary Care Provider Services................20 8.2 Endorsements/Optional Benefits.........................40
4.6.3 Primary Care Provider................................21 8.2.1 Chiropractic or Acupuncture Care.............40
4.6.4 Specialty Care Providers ...........................21 8.2.2 Vision..........................................................40
4.6.5 PCP Changes ............................................21 8.3 Valued-Added Services........................................40
4.6.6 Outstanding Referrals ...............................21 8.3.1 Prenatal Program.......................................40
4.6.7 Limiting or Closing Practice.......................21 8.3.2 Prenatal Vitimin Program...........................40
4.7 Appeals Process...................................................22 8.3.3 Condition Support Program......................40
Section 5: Referrals.........................................................24 8.3.4 AccordantCare® Rare Disease
5.1 Referral Policy........................................................24 Management Program...............................41
5.2 Retroactive Referrals Policy Change������������������� 24 8.3.5 CaféWell.....................................................41
5.3 Referral Procedure����������������������������������������������� 24 8.3.6 Hospital-based Health Education
5.4 Referral Management Entities����������������������������� 25 Classes........................................................41
5.5 Out-of-Panel Referrals����������������������������������������� 25 8.3.7 Prescription Discount Program.................42
5.6 Referral Not Required������������������������������������������26 8.3.8 Chronic Disease Self-management
5.6.1 List of Services...........................................26 Program......................................................42
5.7 Referrals That Are Not Approved.........................26 8.3.9 Tobacco Cessation Program.....................42
8.3.10 Global Emergency Services.....................43
Section 6: Medical Management����������������������������������27
6.1 Medical Necessity.................................................27 Section 9: Members�������������������������������������������������������44
6.2 Case Management...............................................27 9.1 Enrollment............................................................. 44
6.3 Preauthorization....................................................28 9.2 ID Card................................................................. 44
6.3.1 Services Requiring Preauthorization..........28 9.3 Networks...............................................................45
6.3.2 Preauthorization Policy..............................30 9.4 Members’ Rights and Responsibilities.................45
6.3.3 Sleep Disorder Treatment.........................30
6.3.4 Preauthorization Procedure.......................32
6.3.5 Retrospective Preauthorizations...............33
Contents
Section 10: Filing Claims������������������������������������������������47 11.5.3 Multiple and Bilateral Surgical Procedures
10.1 Eligibility and Benefits.........................................47 Performed in the Same Operative
10.2 1500 Health Insurance Claim Form Session......................................................68
Instructions...........................................................47 11.5.4 Ambulatory Surgery Center Billing
10.2.1 CMS 1500 Form Implementation...........50 Guidelines .................................................70
10.3 UB04 Instructions...............................................50 11.5.5 Surgical Assistant Guidelines...................71
10.4 HCPCS Coding....................................................52 11.5.6 Office Surgery Suites and Fees...............71
10.5 Electronic Medical Claims...................................53 11.5.7 Payment Rules for Multiple Scope
10.6 Explanation of Payment (EOP) ..........................53 Procedures................................................72
10.6.1 How to Read Your EOP...........................53 11.6 Evaluation and Management (E&M) Billing
10.7 Prompt Pay Policy...............................................56 Guidelines.............................................................73
10.8 Accident Report Policy........................................56 11.6.1 Preventive Visits and E&M Billed
10.8.1 On-the-Job Injury.....................................56 Together....................................................73
10.8.2 Motor Vehicle Accident...........................56 11.6.2 Appropriate Use of CPT Code 99211......75
10.8.3 Third Party Liability...................................57 11.6.3 Anticoagulant Management Codes.........75
10.9 Coordination of Benefits.....................................57 11.6.4 Distinction Between New and
10.9.1 Group Health Insurance Coverage..........57 Established Patients.................................76
10.9.2 Individual Health Insurance Coverage.....57 11.7 Ambulatory Surgery Center (ASC) Payment
10.9.3 Nondependent or Dependent.................57 Guidelines.............................................................76
10.9.4 Dependent Child Whose Parents Live 11.7.1 Services included in the ASC Facility
Together....................................................57 Payment....................................................76
10.9.5 Dependent Child of Divorced or 11.7.2 Services Not Included in the
Separated Parents ...................................57 ASC Facility Payment...............................77
10.9.6 Active/Inactive Employees .....................58 11.8 Ultrasound: Same-day Billing of Transvaginal
10.9.7 COBRA or State Continuation and Standard ������������������������������������������������������77
Coverage...................................................58 11.9 Never Events Policy.............................................78
10.9.8 Longer/Shorter Length of Coverage.......58 11.9.1 Surgical Events.........................................78
10.10 Document Imaging............................................58 11.9.2 Product or Device Events........................78
10.11 Overpayments...................................................58 11.9.3 Case Management Events......................78
10.12 Corrected Claims Submission...........................59 11.9.4 Environmental Events..............................79
11.10 Modifiers............................................................79
Section 11: Billing Requirements�����������������������������������60 11.11 Place of Service Codes For Professional
11.0 Incident to Billing.................................................60 Claims.................................................................81
11.1 Osteopathic Manipulation Treatment..................61 11.12 Routine Venipuncture and/or Collection of
11.2 Global Period........................................................62 Specimens..........................................................82
11.3 Obstetric and Gynecology Care 11.13 Lab Handling Codes...........................................83
Billing Guidelines..................................................62 11.14 Clinical Lab Services..........................................83
11.3.1 Global OB Care.........................................62 11.15 Editing Software for Facility and Professional
11.3.2 Partial Services.........................................63 Claims.................................................................83
11.3.3 Multiple Births..........................................64 11.15.1 Professional Claims.................................83
11.3.4 Annual Gynecological Exams..................65 11.15.2 Facility Claims.........................................83
11.3.5 Screening Papanicolaou Smear 11.15.3 Sample Edit Criteria................................84
HCPCS code Q0091................................65 11.15.3 Other Generalized Edits..........................84
11.4 Emergency Services...........................................66 11.16 Vision—Routine vs. Medical.............................84
11.4.1 Emergency Room Claims Not
Approved ..................................................66 Section 12: Publications and Tools��������������������������������86
11.4.2 Emergency and After-Hours Codes 12.1 Provider Directories.............................................86
Defined .....................................................66 12.2 Newsletters.........................................................86
11.5 Surgery.................................................................67 12.3 Website...............................................................86
11.5.1 Bilateral Procedures..................................67 12.3.1 PacificSource.com....................................86
11.5.2 Multiple Procedures.................................68 12.3.2 InTouch for Providers...............................87
12.4 Second Language Material.................................87
Section 1 | Introduction
1.1 About This Manual
Thank you for becoming a team member in the
partnership between PacificSource, our employer
The PacificSource Provider Network department groups and members, and our participating physicians
assembled this manual to give participating providers and providers.
helpful and reliable information and guidelines. The
manual is organized into sections and then into
specific topics. 1.2 PacificSource Mission
The PacificSource Physician and Provider Manual Statement
is your desktop reference for information about
PacificSource commercial policies and procedures and The Mission of PacificSource
can also be used as a training tool when familiarizing To provide better health, better care, and better cost to
new employees to PacificSource. For the purpose of the people and communities we serve
brevity, we use the term “provider” throughout the
manual to refer to physicians and/or providers. Provider Network Department Mission
Please note the comments at the bottom of To create and maintain partnerships among internal
some pages. This information gives you quick and and external customers resulting in adequate access
easy reference related to physician and provider to quality service in a competitive market
responsibilities and/or instructions. Updates are
announced in The Provider Bulletin newsletter and on
our website, PacificSource.com.
Take a moment to look over the sections that relate
to your responsibilities. You will find the expanded
glossary helpful in becoming familiar with common
insurance terminology and, of course, your comments,
questions and/or suggestions are always welcome.
PacificSource Provider Service Representatives are
committed to providing tools that meet the needs of
our participating physicians and providers.
1
Section 1 | Introduction
1.3 PacificSource History
PacificSource Administrators), an administrator of
flexible spending accounts, health reimbursement
Serving Lane County, Oregon: 1933–1973 arrangements, and COBRA benefits; and Select
Benefit Administrators (renamed PacificSource
PacificSource was founded in 1933 by a group of 21
Administrators), an administrator of self-funded
physicians who staffed and operated Pacific Christian
employee benefit plans. These new product lines
Hospital in Eugene, Oregon. Within two years the
allowed PacificSource to offer a full range of benefit
company covered 600 employees, hired the first full-
solutions to employers and paved the way for growth
time manager, and took on the name Pacific Hospital
beyond Oregon.
Association (PHA).
By 1940, the not-for-profit PHA focused on providing From Statewide to Regional: 2005–Present
health coverage to mostly wood product companies In 2007, PacificSource achieved a key goal of its
and government employers, such as Giustina Brothers expansion strategy by entering the Idaho market and
Lumber Company, Westfir Lumber Company, Lane opening a regional office in downtown Boise, Idaho.
County, and the City of Eugene. PHA fulfilled the It celebrated its 75th anniversary in 2008, ending
needs of local employers who wanted to ensure their the year with 150,000 covered members and newly
employees could access care if they were sick and acquired licensure in Washington.
would be protected financially.
In 2009 PacificSource enhanced its Idaho market
Slow, steady growth and solid resources made PHA presence and its dental membership through two
an attractive company, and twice during the early acquisitions: Primary Health, Inc., of Idaho, including
1940s the firm rejected offers to merge. By 1945 PHA Primary Health Plan, Riverside Benefit Administrators,
insured 4,500 working men and women at $2 per and Idaho Physicians Network; and Advantage Dental’s
month. The company celebrated its 20th anniversary commercial dental business. Through this growth
in 1953 with 10,500 members, 123 business PacificSource finished 2009 with 206,000 members.
contracts, and 67 physicians.
In keeping with its vision of becoming the leading
Expanding throughout Oregon: 1973–2005 community health plan in the region, PacificSource
entered the Medicare and Medicaid markets in 2010
By 1975, PHA had become a major health insurer for
through the acquisition of Clear One Health Plans,
Lane County, Oregon, residents. During the financially
Inc. This union combined Clear One’s expertise
difficult 1980s, thanks to conservative underwriting
in government programs with PacificSource’s
practices and measured growth, PHA avoided the large
longstanding leadership as a commercial health plan,
financial losses that plagued many other health insurers
providing greater opportunity to collaborate with
and emerged stronger than ever. In 1985 and 1986 PHA
providers across a broader spectrum of patients to
expanded its western Oregon marketing area to include
improve healthcare quality and access.
Douglas, Linn, Coos, and Benton Counties.
Through the acquisition of Clear One, PacificSource
The company grew dramatically in the 1990s thanks to
also gained a foothold in the Montana market with
aggressive provider contracting and marketing efforts.
1,500 members and began its expansion in that
In 1992, PHA opened an office in Portland, Oregon,
state. In 2011 PacificSource opened an office in
and in 1994 the company launched its own line of
Helena, achieved licensure in Montana, and signed an
group dental plans. The organization adopted the
agreement to purchase a portion of New West Health
name PacificSource Health Plans in October 1994 to
Services’ commercial health insurance business.
better reflect its mission as a health insurer. By the late
1990s, PacificSource had become a statewide plan, Now, as a full-service organization with licensure
providing businesses and individuals in all corners of in four states, PacificSource is well positioned to
Oregon with flexible health and dental insurance. expand on its role as a community healthcare asset.
Offering healthcare solutions for individuals, small
To better serve its growing customer base,
companies, large organizations, and government
PacificSource opened offices in Bend in 2000 and in
programs, PacificSource is able to meet the needs of
Medford in 2004. In 2003 PacificSource acquired two
all community members.
third-party administrators: Manley Services (renamed
2Section 2 | Who to Contact
Customer Service Fax numbers
Oregon: (541) 225-3625
Oregon: (541) 684-5582, (888) 977-9299 Idaho: (208) 395-2697
Idaho: (208) 333-1596, (800) 688-5008 Montana: (406) 441-3378
Montana: (406) 442-6589, (877) 590-1596
Fax: (541) 684-5264 Email: healthservices@pacificsource.com
Email: cs@pacificsource.com
Contact for:
Contact for: • Referrals
• Benefits • Case management
• Explanation of payments/vouchers • Utilization review
• Participating physicians and providers • Preauthorization
• Pharmacies and networks • Out-of-panel referral information
• Claim questions/status • Specific medical necessity criteria/guidelines
• PCP changes
•
•
Referral status
Appeal process Individual Sales Department
• Accident information Oregon: (541) 684-5585, toll-free (866) 695-8684
Idaho: (208) 333-1559, toll-free (855) 333-1559
Montana: (406) 442-6609, toll-free (888) 684-5585
Credentialing Fax numbers
(541) 684-5580, (800) 624-6052, ext. 3747
Oregon: (541) 225-3646
Fax: (541) 225-3644
Idaho: (208) 342-4508
Email: credentialing@pacificsource.com
Email: individual@pacificsource.com
Contact for:
• Direct credentialing inquiries Contact for:
• Direct credentialing application status • Elect products including Portability
• Direct recredentialing inquiries • MediShield/Medicare supplement
Dental Customer Service
(541) 225-1981, (866) 373-7053
Fax: (541) 684-5564
Email: dental@pacificsource.com
Health Services
Our Health Services staff is available Monday through
Friday, 8:00 a.m. to 5:00 p.m. to answer calls. After
normal business hours, calls to Health Services
are forwarded to voice mail. A staff member will
return the call the next business day. Any email
communication received after hours will be answered
the following business day.
Oregon: (541) 684-5584, (888) 691-8209, ext. 2584
Idaho: (208) 333-1563, (800) 688-5008
Montana: (406) 442-6595, (877) 570-1563
TTY: (800) 735-2900
3Section 2 | Who to Contact
Marketing Department • Adding and terminating employees
• Member ID cards
Oregon: (541) 686-1242, (800) 624-6052 • Member address changes
Idaho: (208) 908-5801, toll-free (888) 492-2875
Montana: (406) 422-1008
Fax: (541) 225-3645 Pharmacy Services
Email: groupsales@pacificsource.com
(541) 330-4999, toll-free (888) 437-7728
TTY: (800) 735-2900
Contact for:
• Sales Contact for:
• Quotes of optional benefits
• Exceptions to standard formulary rules
• Group supply orders
• Group service • Prior authorization for all medications (medically
• Policy change administered and pharmacy)
• Clinical consultation
Marketing Offices Provider Contracting/Reporting
Contact for: (541) 684-5580, (800) 624-6052, ext. 2580
• Sales Fax: (541) 225-3643
• Quotes of optional benefits Email:
• Group supply orders Idaho: IDcontracting@pacificsource.com
• Group service Montana: MTcontracting@pacificsource.com
• Policy change Oregon: ORcontracting@pacificsource.com
Washington: WAcontracting@pacificsource.com
Portland All States: ProviderContracting@pacificsource.com
(503) 699-6561, (800) 624-6052, ext. 2513
Fax: (503) 697-1075
Email: groupsales@pacificsource.com
Contact for:
• Contract negotiations
Bend • Contract concerns/clarifications
(541) 330-8896, toll-free (888) 877-7996 • Physician/provider contract reports
Fax: (541) 330-8948 • Physician/provider utilization reports
Email: groupsales@pacificsource.com
Medford
(541) 858-0381, (800) 899-5866
Provider Customer Service
Fax: (541) 858-0486 To better serve you, and to reduce on-hold wait times,
Email: groupsales@pacificsource.com we’ve added a new toll-free customer service phone line
especially for commercial providers: (855) 896-5208.
Membership Service Contact for:
(541) 684-5583, (866) 999-5583 • Verify member benefits
Fax: (541) 225-3642 • Check the status of referrals
Email: membership@pacificsource.com • General questions
Contact for:
• Enrollment eligibility
• Continuation
• Billing
4Section 2 | Who to Contact
Provider Network 2.1 Provider Network Management
Physician/provider support and education The Provider Network department operates as a
(541) 684-5580, (800) 624-6052, ext. 2580 liaison between PacificSource Health Plans and
TTY: (800) 735-2900 healthcare professionals. Recognizing the needs
Fax: (541) 225-3643 and perspectives of participating physicians and
Email: providernet@pacificsource.com providers, Provider Network Management is dedicated
to giving our physicians and providers the highest
Contact for: quality service, with a commitment to working with
practitioners in a fair, honest, and timely fashion.
• Physician/provider contract support
• Call share maintenance Provider Service representatives are a division of the
• Physician/provider panel information Provider Network department. The Provider Network
• Limited practice designations Management staff and service representatives have
• Demographic updates, including tax ID numbers the following defined purposes and responsibilities:
• Physician/provider credentialing
• Develop and provide support services to new and
established contracted physicians and providers
for the purpose of contract education, compliance,
and problem solving, and to ensure satisfaction
with PacificSource.
• Provide liaison support internally for physician- and
provider-related issues, including questions or
concerns regarding contracts and operations.
• Develop educational materials for meetings and/or
mailings as needed.
• Develop and maintain a Provider Manual
outlining general information about PacificSource
policies and procedures applicable to healthcare
professionals.
• Present contracted physicians and providers
to members via current and accurate provider
directories.
• Identify and pursue opportunities for provider
network expansion and enhanced member access
to healthcare.
5Section 3 | Glossary of Terms
Access: Ability to obtain medical services. Benefit Package: Specific services provided by the
insurance carrier.
Accreditation: Accreditation programs give an official
authorization or approval to an organization against a Benefit Plan: Covered services, co-payments or
set of industry-derived standards. deductible requirements, limitations, and exclusions
contained in the contract between PacificSource and a
Actuary: A person in the insurance field who member or subscriber group.
determines insurance policy rates and conducts
various other statistical studies. Board Certified: A physician who has passed an
examination given by a medical specialty board.
Adjudication: Processing a claim through a series of
edits to determine proper payment. Board Eligible: A physician who has graduated from
an approved medical school and is eligible to take a
Administrative Services Only (ASO) Contract: specialty board examination.
A contract between an insurance company and a
self-insured plan where PacificSource performs Call Share: The physicians or providers on whom a
administrative services only; for example, claims practitioner relies for backup coverage during times he/
processing. she is unavailable.
Allied Health Professional (AHP): All healthcare Call Share Group: A group of providers with similar
providers who are not licensed as doctors of medicine specialties who have joined together to provide call
or osteopathy; for example, nurse practitioners, share services.
physician assistants, and chiropractors.
Capitation: A method of paying for medical services
Alternative Care: Medical care received in lieu of on a per-person rather than a per-procedure basis.
inpatient hospitalization. Examples include outpatient Under capitation, PacificSource pays a participating
surgery, home healthcare, and skilled nursing facility physician or provider a fixed amount per month for
care. It also may refer to nontraditional care delivered every PacificSource member he/she takes care of,
by providers, such as acupuncturists. regardless of the care the member receives.
Ambulatory Care: Healthcare services rendered in a Carrier: Insurer, underwriter of risk.
hospital’s outpatient facility, physician’s office, or home
healthcare; often used synonymously with the term Carve Out: An arrangement in which an employer or
“outpatient care.” health plan removes or retains coverage for a specific
category of services (for example, mental health,
Ancillary Medical Service: Covered service substance abuse, vision care, or prescription drugs),
necessary for diagnosis and treatment of members. and arranges for coverage through a contract with a
Includes, but is not limited to, ambulance, ambulatory separate set of providers. The health plan’s contract
or day surgery, durable medical equipment, imaging with these providers may specify certain payment and
service, laboratory, pharmacy, physical or occupational utilization management arrangements.
therapy, urgent or emergency care, and other covered
service customarily deemed ancillary to the care Case Management: The process whereby a
furnished by primary care or specialist physicians or healthcare professional supervises the administration
providers. of medical or ancillary services to a patient, typically
one who has a catastrophic disorder or who is
Appeal Process for Terminated Providers: The receiving mental health services. Case managers
system for the receipt, handling, and disposition of reduce the costs associated with the care of such
provider complaints and grievances in regards to patients, while providing high-quality medical services.
contract termination, as described in the PacificSource
Policies and Procedures. Case Rate: A “package price” for a specific procedure
or diagnosis-related group.
Behavioral Healthcare: Treatment of mental health
and/or substance abuse disorders.
6Section 3 | Glossary of Terms
Clinic: A healthcare facility for providing preventive, Covered Services: Healthcare services which a
diagnostic, and treatment services to patients in an member is entitled to receive from PacificSource.
outpatient setting.
Credentialing: A process of screening, selecting,
Closed Grievance (also see Grievance): A decision and continuously evaluating individuals who
that has been made which cannot be appealed or is provide independent patient care services based
not under appeal by the member. on their licensure, education, training, experience,
competence, health status, and judgment.
Co-insurance: A policy provision under which the
insured pays or shares part of the medical bill, usually Deductible: The portion of the member’s healthcare
according to a fixed percentage. expenses that must be paid out of pocket before any
insurance coverage is applied.
Complaint: An expression of dissatisfaction about a
specific problem encountered by a member, or about Dependents: Eligible family members of the
a decision by the insurer (or agent acting on behalf of subscriber covered by a health insurance plan.
the insurer). A complaint must include a request for
action to resolve the problem or change the decision. Diagnosis: The identification of a disease or condition
through examination.
Consolidated Omnibus Budget Reconciliation
Act (COBRA): A law that requires employers to Diagnosis-Related Groups (DRG): A program in
offer continued health insurance coverage to eligible which hospital procedures are rated in terms of cost
employees whose health insurance coverage and intensity of services delivered. A standard rate per
terminates. procedure is paid, regardless of the cost to the hospital
to provide that service.
Coordination of Benefits (COB): An insurance
provision that allocates responsibility for payment Disability: Any medical condition that results in
of medical services between carriers if a person is functional limitations that interfere with an individual’s
covered by more than one insurance plan. ability to perform his/her normal work, and results in
limitations in major life activities.
Coordinated Care Organization (CCO): A network
of all types of healthcare providers who have agreed Disclaimer: A form supplied by PacificSource for
to work together in their local communities for people managed care physicians and providers to use when
who receive health care coverage under the Oregon a patient presents for services without a referral
Health Plan (Medicaid). to a specialist. It may also be used when a patient
accesses services of a primary care practitioner who
Co-payment: The portion of the claim or medical is not the patient’s designated PCP or is not in the
expense that a member (or covered insured) must pay PCP’s call share group. The patient/subscriber is asked
out of pocket. to sign this form indicating that they understand they
may be financially responsible for charges incurred
Cost Containment: A strategy that aims to reduce during the visit.
healthcare costs and encourages cost-effective use
of services. Dual Option: The choice between two or more
different arrangements for medical care (for example,
Cost Sharing: A general set of financing indemnity insurance or a managed care organization).
arrangements via deductibles, co-payments, or
coinsurance in which a person covered by a health Durable Medical Equipment (DME): Equipment that
plan must pay some of the cost to receive care. can be repeatedly used, is primarily and customarily
used to serve a medical purpose, is generally not
Coverage: Services or benefits provided through a useful to a person in the absence of illness or injury,
health insurance plan. and is appropriate for use at home. Examples include
Covered Lives: Total of insured members. hospital beds, wheelchairs, and oxygen equipment.
7Section 3 | Glossary of Terms
Emergency Medical Condition: A medical condition Fee-for-Service: The traditional method of paying for
that manifests itself by symptoms of sufficient medical services. A doctor charges a fee for each service
severity to convince a prudent layperson that failure to provided and the insurer pays all or part of that fee.
receive immediate medical attention would place the
health of a person (or a fetus in the case of a pregnant Fee Schedule: List of fees for specified medical
woman), in serious jeopardy. Examples include heart procedures.
attacks, cardiovascular accidents, poisonings, and loss Formulary: PacificSource Health Plan’s list of
of consciousness or respiration. approved prescription medications that generally carry
Emergency Medical Screening Exam: The medical a lower co-payment.
history, examination, ancillary tests, and medical Full Risk: An arrangement where PacificSource has
determinations required to ascertain the nature and given the medical group or provider organization
extent of an emergency medical condition. financial responsibility for the comprehensive
Emergency Services: Healthcare items or services healthcare needs of the patient. Full risk includes
furnished in an emergency department, and ancillary both the institutional and professional components of
services routinely available to an emergency capitation with no sharing of savings with the health
department, when needed to stabilize a patient. plans and generally includes home health, skilled
PacificSource expands the definition as the sudden nursing facilities, ambulance, and acute hospital and
and unexpected onset of a condition requiring physician services.
immediate medical or surgical care, which the Gatekeeper: See Primary Care Practitioner.
member secures immediately after the onset, or as
soon thereafter as can be made available, but in any Global: All-inclusive.
case no longer than 24 hours after the onset.
Grievance: A written complaint submitted by, or on
Enrolled Group (see also Contract Group): A group behalf of, a member regarding any of the following: the
of persons enrolled in a health plan through their availability, delivery, or quality of healthcare services;
employer or other common organization of which the utilization review decisions; claims payment, handling or
persons are members. reimbursement for healthcare services; or the contractual
relationship between a member and an insurer.
Enrollee: A person eligible for service as either a
subscriber or a dependent. Hospice: A healthcare service that provides
supportive care for the terminally ill.
Enrollment: The process by which an individual
becomes a subscriber for coverage in a health plan. Independent Physician Association (IPA): An
individual practice association of physicians and/
Episode of Care: All treatment rendered in a specified or providers that have entered into a contract with
time frame for a specific disease. PacificSource to provide certain specific covered
Experience Rating: Rating system by which a plan services to members.
determines the capitation rate or premium based on Individual Practice Association (IPA): An individual
the experience of the individual group enrolled. practice association of physicians and/or providers that
Experimental Procedures: Also called unproved entered into a contract with PacificSource to provide
procedures. All healthcare services, supplies, certain specific covered services to members.
treatments, or drug therapies that PacificSource has Inpatient Care: Healthcare provided in a licensed
determined are not generally accepted by healthcare bed in a hospital, nursing home, or other medical or
professionals as effective in treating the illness for psychiatric institution.
which their use is proposed.
Inquiry: A written request for information or
Extended Care Facility: A nursing home-type setting clarification about any matter related to the member’s
that offers skilled, intermediate, or custodial care. health plan. An inquiry is not a complaint.
8Section 3 | Glossary of Terms
Joint Commission on Accreditation of Healthcare Medically Necessary Covered Services: Services
Organizations (JCAHO): A private, nonprofit that PacificSource determines, through its professional
organization that evaluates and accredits healthcare review process, are (i) appropriate for the symptoms
organizations providing mental health care, ambulatory and diagnosis or treatment of a member’s medical
care, home care, and long-term care services. condition, (ii) provided for in the diagnosis or the
direct care and treatment of that medical condition,
Loss Ratio: The ratio of a health maintenance (iii) provided in accordance with standards of good
organization’s actual incurred expenses to total medical practice, (iv) not primarily for the convenience
premiums. of the member or the member’s provider of care, and
Managed Care: A system of healthcare delivery (v) the most appropriate level of service that can be
developed to manage the cost, quality, and access safely provided to the member.
of care. It is characterized by a contracted panel of Medicare: The federal health insurance program for
physicians and/or providers; use of a primary care older U.S. citizens and the disabled.
practitioner; limitations on benefits provided by
noncontracted physicians and/or providers; and a Member: Any PacificSource subscriber or dependent
referral authorization system for obtaining care from as determined by PacificSource.
someone other than the primary care practitioner.
Negotiated Discount: Method of reimbursement
Managed Care Coordinator/Committee: An for contracted physicians and providers that stipulates
individual and/or committee that receives referral a specific percentage by which a charge may be
authorization requests and, based on a strict set of reduced if included in the physician’s or provider’s
criteria, either approves or denies a request for referral contract or agreement.
authorization.
Network: The doctors, clinics, health centers, medical
Managed Fee-for-Service Product: Plan in which the group practices, hospitals, and other providers that
insurer pays the cost of covered services after the services PacificSource has selected and contracted with to
have been used. Various managed care tools such as provide healthcare for its members.
preauthorization, second surgical opinion, and utilization
review are used to control inappropriate utilization. Noncovered Services: Those services excluded from
coverage by PacificSource.
Medicaid: The federal-state health insurance program
for low-income U.S. citizens. Medicaid also covers Non-Emergent Condition: Routine physical or eye
nursing-home care for the indigent elderly. examinations, diagnostic work-ups for chronic conditions,
routine prenatal care, elective surgery, and scheduled
Medical Group: A group of physicians and/or follow up visits for prior emergency conditions. In these
providers organized as a single professional entity that instances, no benefits are payable for service/treatment
is recognized under state law as an entity to practice a provided in an emergency room setting.
medical profession.
Nonformulary Covered Prescriptions: A list of
Medical Services Contract: A contract to provide prescription drugs that generally carry a higher
medical or mental health services that exists between co-payment.
an insurer, physician or provider, and independent
practice association; between an insurer and a Nonparticipating Provider: A healthcare physician
physician or provider; between an independent or provider who has not contracted with PacificSource
practice association and a provider or organization of Health Plans.
providers; between medical or mental health clinics; Nurse Practitioner: A registered nurse who
or between a medical or mental health clinic and a has advanced skills, training, and licensure in the
physician or provider. This does not include a contract assessment of physical and psychosocial health status
of employment or a contract creating legal entities of individuals, families, and groups.
and ownership thereof that are authorized under ORS
chapters 58, 60 or 70, or other similar professional Out-of-Area: Any area that is outside the
organizations permitted by statute. PacificSource service area.
9Section 3 | Glossary of Terms
Out-of-Panel Physician or Provider: A physician or Physician-Hospital Organization (PHO): A
provider who is not a part of the panel. healthcare delivery organization including both
physicians and providers and a hospital or hospitals,
Outpatient Care: Care given to a person not requiring which has entered into a contract with PacificSource
a stay in a licensed hospital or nursing home bed. to provide specified covered services to members.
PacificSource Health Plans: A healthcare service Plan: See Group Health Plan.
contractor licensed under state law that contracts for
the provision of comprehensive healthcare services for Plan Administration: Management of a plan,
its members enrolled in various benefit plans. including accounting, billing, personnel, marketing,
legal services, purchasing, and servicing of accounts.
PacificSource Policies and Procedures: The terms
and conditions adopted by PacificSource for the Plan Sponsorship: A group that organizes the group
administration of health benefits. health plan, oversees its facilities, and provides
managerial authority.
PacificSource Service Area: The geographic area
defined by the boundaries of the states of Oregon Point of Service: A health plan that allows members
and Idaho; the Washington counties of Clark, Cowlitz, to choose a participating or nonparticipating provider
Klickitat, Pacific, Skamania, and Wahkiakum; and the (with or without a referral), with benefit levels that
Idaho counties of Ada, Boise, Canyon, Elmore, Gem, differ depending on whether or not the provider
Owyhee, Payette, and Washington. participates in the plan’s network.
Panel Physician or Provider: An individual physician or Policyholder: The employer or individual to which
provider who has entered into an agreement with an IPA, a contract is issued and in whose name a policy is
or other association of healthcare practitioners to provide written. In a plan contracted directly with the individual
certain contracted services to PacificSource members. or family, the policyholder is the individual to whom
the contract is issued.
Participating Provider Panel: An IPA or other
association of physicians and/or providers organized as Portability: Access to continuous health coverage
a single professional entity, which enters into a service so the insured does not lose insurance coverage due
agreement with PacificSource for the provision of to any change in health or personal status (such as
certain covered services to PacificSource members. employment, marriage, or divorce).
PCP: See Primary Care Practitioner. Preauthorization: An approval process prior to
the provision of services, usually requested by the
Per Diem: The negotiated daily payment rate for physician or provider. Factors determining authorization
delivery of all inpatient or residential services provided may be eligibility, benefits of a specific plan, or setting
in one day, regardless of the actual services provided. of care.
Per diems can also be developed by type of care
(for example, one per diem rate for general medical/ Pre-Existing Condition: Physical condition of an
surgical care and a different rate for intensive care). insured person that existed before the issuance of a policy
or enrollment in a plan. Pre-existing conditions may result
Per Member Per Month (PMPM): A negotiated rate in a limitation in the contract on coverage or benefits.
of payment per enrollee per month. A fixed amount
determined by a negotiated rate between an insurance Preferred Provider Organization (PPO): Fee-for-
carrier and physician or provider. service product where participants have financial
incentives to seek care from participating physicians
Physician: A person duly licensed and qualified to practice and providers, but are allowed to go to nonparticipating
medicine in the state where his/her practice is located. physicians and providers at a reduced benefit.
Physician Assistant: A healthcare professional qualified Premium: Rate that is paid for a specific health service.
by education, training, experience, and personal
character to provide medical services under the
direction and supervision of a licensed physician in
active practice and in good standing with the Board.
10Section 3 | Glossary of Terms
Preventive Care: An approach to healthcare Reinsurance: Insurance purchased by a carrier from
emphasizing preventive measures, such as routine another insurance company to protect itself against all
physical exams, diagnostic tests (e.g., PAP tests), and or part of the losses that may be incurred by claims for
immunizations. its members (e.g., catastrophic care).
Primary Care Practitioner (PCP): Physician or Resource-Based Relative Value Scale (RBRVS):
provider selected by a member who shall have the A financing mechanism that reimburses healthcare
responsibility of providing initial and primary care providers on a classification system.
and for referring, supervising, and coordinating the
provision of all other covered services to the member. Risk: A possibility that revenues of the insurer will not
A PCP may be either a family physician or provider, sufficiently cover expenditures incurred in the delivery
general practitioner, internist, pediatrician, obstetrician, of contractual services.
gynecologist, or other practitioner or nurse practitioner Risk Contract: An arrangement through which a
who has otherwise limited his/her practice of medicine healthcare provider agrees to provide a full range of
to general practice or a specialist practitioner who has medical services to a set population of patients for a
agreed to be designated as a primary care practitioner. prepaid sum of money or a predetermined budget. The
Managed Care plans require that each enrollee be physician or provider is responsible for managing the
assigned to a primary care practitioner. care of these patients, and risks losing money if total
Protocol: Description of a course of treatment or an expenses exceed the predetermined amount of funds.
established practice pattern. Risk Pool: A category of services that are subject
Provider: A person licensed, certified, or otherwise to some type of projected expense target. Typically,
authorized by federal and/or state law to administer amounts over or under this target are shared with
medical or mental health services in the ordinary the medical group “at risk” for these services.
course of business or practice of a profession. For example, if the risk pool is set at $25.00 (per
PacificSource further defines providers as physicians, member per month) for hospital services and the
dentists, nurses, physician assistants, podiatrists, actual amount comes in at $26.00, the $1.00 over the
chiropractors, acupuncturists, naturopaths, targeted amount may be deducted from other areas of
optometrists, mental health professionals, physical, reimbursement to the medical group.
speech, and occupational therapists, pharmacists, Risk Sharing: An arrangement in which financial
and other healthcare facilities or entities, including liabilities are apportioned between two or more entities.
Individual Practice Associations or Medical Groups For example, PacificSource and a provider may each
engaged in the delivery of healthcare services. agree to share the risk of excessive healthcare cost over
Quality Assurance Program: A program and process budgeted amounts on a 50-50 basis.
that is carried out by PacificSource and contracted Self-Insured: Management in which health services
physicians and providers to monitor, maintain, and are delivered by physicians and/or providers, but the
improve the quality of services provided to members cost of these services is covered by the member’s
as described in PacificSource Policies and Procedures. employer, instead of by the insurance firm.
Quality Improvement: A continuous process that Service Areas: Geographic areas covered by a
identifies problems in healthcare delivery, tests PacificSource insurance plan where direct services
solutions to those problems, and monitors the are provided.
solutions for improvement.
Skilled Nursing Facility (SNF): A facility, either
Referral: The process by which the member’s primary freestanding or part of a hospital, that accepts patients
care practitioner directs the member to seek and obtain in need of rehabilitation and/or medical care that is of a
covered services from other physicians and providers. lesser intensity than that received in a hospital.
Referral Authorization: The process of reviewing
and authorizing referrals to specialists by primary care
practitioners.
11Section 3 | Glossary of Terms
Solo Practice: Individual practice of medicine by a Utilization: The extent to which the members of a
physician or provider who does not practice in a group covered group use the services or procedures of a
or share personnel, facilities, or equipment, with other particular healthcare benefit plan.
physicians.
Utilization Review: A set of formal techniques used
Specialist Physician/Provider: A physician or by (or delegated by) an insurer that are designed to
provider whose training and expertise are in a specific monitor the use of or evaluate the medical necessity,
area of medicine. appropriateness, efficacy, or efficiency of healthcare
services, procedures, or settings.
Stabilization: A state in which, within reasonable
medical probability, no material deterioration of an Utilization Management Program: The programs
emergency medical condition is likely to occur. and processes established and carried out by
PacificSource with the cooperation of contracted
Stop-Loss: Risk protection from withhold losses physicians and providers to authorize and monitor the
resulting from claims greater than a specific dollar utilization of covered services provided to subscribers.
amount per member per year.
Subrogation: When healthcare costs of enrollees are
the responsibility of an entity other than the insurer,
such as workers’ compensation, third party negligence
liability, or automobile medical coverage.
Subscriber: The person who is responsible for
payment to PacificSource, or whose employment or
other status (except for family dependency), is the
basis for eligibility for membership in PacificSource.
Supplemental Medicare: A plan that covers some
co-payments, deductibles, and other services not
covered under traditional Medicare.
Tertiary Care: Healthcare services that are not
available through a community hospital setting. This
may include complex cancer procedures, transplants,
and neonatal intensive care.
Third Party Administrator (TPA): An independent
person or corporate entity that administers group
benefits, claims, and administration for a self-insured
group or insurance company. A TPA does not
underwrite risk.
Third Party Payment: Payment for healthcare by a
party other than the member.
Triage: The classification of sick or injured persons,
according to severity, in order to direct care and ensure
efficient use of medical and nursing staff and facilities.
Urgent Care Clinic: A healthcare facility whose
primary purpose is the provision of immediate,
short-term medical care for minor, but urgent,
medical conditions.
12Section 4 | Physicians and Providers
4.1 Eligible Providers 4.1.1 Eligible Mental Health and
The following physicians and practitioners are eligible
to be considered as PacificSource participating
Substance Abuse Professional
providers, provided they meet credentialing Providers
requirements. • Clinical social workers licensed by a State Board of
Clinical Social Workers
Physicians and Practitioners • Medical or osteopathic physicians licensed by a
• Doctor of Medicine State Board of Medical Examiners
• Doctor of Osteopathy • Nurse practitioners registered by a State Board of
• Oral Surgeon, Doctor of Dental Medicine Nursing
• Podiatrist • Psychologists (PhD) licensed by a State Board of
Psychologist Examiners
Allied Health Care Practitioners • In Oregon, psychologist associates and the
• Audiologist supervising licensed psychologist must have an
agreement to provide continued supervision of
• Certified Nurse Midwife the professional work of a licensed psychologist
• Certified Registered Nurse Anesthetist associate by the Oregon Board of Psychologist
• Clinical Nurse Specialist (with concurrent NP, Examiners (we will review eligibility of psychologist
CRNA, or CRNFA licensure only) associates outside Oregon on a case-by-case basis).
• Licensed Clinical Social Worker • Licensed Professional Counselors and Licensed
Marriage and Family Therapists licensed by the
• Licensed Dietician State Board of Licensed Professional Counselors
• Licensed Marriage and Family Therapist and Licensed Marriage and Family Therapists.
• Licensed Professional Counselor (also known as
4.2 Credentialing
Licensed Mental Health Counselor)
• Nurse Practitioner
PacificSource credentialing standards follow the guidelines
• Occupational Therapist of the National Committee on Quality Assurance (NCQA).
• Optometrist The credentialing process includes meticulous verification
• Physical Therapist of the education, experience, judgment, competence, and
licensure of all healthcare providers.
• Physician Assistant
• Psychologist Although the credentialing process may be lengthy
and time-consuming, PacificSource believes the
• Psychologist Associate emphasis on credentialing further demonstrates a
• Speech Therapist commitment to qualified healthcare physicians and
providers performing services our members require.
Please note: Certified Nurse First Assist, Certified First
Assist (CFS), Certified Surgical Technicians, Surgical Please remember that PacificSource requires all
Assistants, and Registered Nurse must bill under the providers rendering services to be individually
overseeing doctor’s tax identification number. credentialed before they can be considered a
participating provider under the provider contact.
Alternative Care Practitioners This includes a nurse practitioner, physician assistant
or other mid-level providers.
• Acupuncturist
• Chiropractor PacificSource does not allow “incident to” billing
• Licensed Massage Therapist for providers that are eligible for credentialing and
• Naturopath practicing under their scope of license.
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